CONSULTANT’S INVOICE
FOR MDH USE ONLY
Purchase Order Number:
Payable to: (please print)
Name
Social Security Number
Billing Address
Federal ID Number
City
State
Date
ZIP
State Tax ID Number
Location
Detailed Description of Service Performed
Calculation of Fees and Expenses
Fee for Professional Services
$
Mileage Calculation
Date
From
Total
Miles
To
Mileage
Rate
$0. 54
Mileage
Reimbursement
$
$0. 54
$
$0. 54
$
Total Mileage Expense
$
Total Air Fare Expense
$
From
receipt)
to
(attach
Total Parking Expense
$
Total Car Rental Expense (attach receipt)
$
Calculation of Meals Expense
Date
Actual Cost for Breakfast
Actual Cost for
Lunch
Actual Cost for
Dinner
Total
$
$
$
$
$
$
$
$
$
$
$
$
Total Meals Expense
$
Total Lodging Expense (attach receipt)
$
Grand Total Reimbursement Requested for Fees and Expenses
$
Certification
I hereby certify that I have performed the services described above and therefore request payment.
Consultant’s Signature
Date
I hereby certify that services indicated above have been performed in accordance with the agreement and approve payment for
these services.
MDH Supervisor’s Signature
DISTRIBUTION:
Original: MDH Financial Management
Date
Copy: MDH Program
HE-01233-12 (01/06)
Copy: Consultant